• Weitsman Site Location:

  • Today's Date

  • Time this report is filled out:

  • Employee's Name (First, Last)

  • Employee's Date of Birth:

  • Employee's Address:

  • Employee's Gender

  • Employee's Age:

  • Employee's Cell Phone Number:

  • Employee's Home Phone Number:

  • Employee's job description:

  • Date and Time of Accident:

  • Number of hours employee worked in the shift this accident occurred:

  • Number of hours employee worked in the week of the accident:

  • Name of Person who reported this accident?

  • Was a Weitsman-owned Vehicle Involved in this accident?

  • Vehicle Year

  • Vehicle Make/Model

  • Vehicle License Plate (State and Number)

  • Pictures taken of:

  • What does the employee report they were doing just before the injury occurred?

  • How did the injury occur?

  • Where (what part of the plant or yard) does the employee report the injury occurred?

  • Did the injury occur in an area where the employee is normally allowed?

  • List witnesses to the event and contact phone number. If there are no witnesses, list "NONE"
  • Witness Name (or None)

  • Witness Phone Number

  • Describe the injury:

  • Which side of the body did the injury occur:

  • Part of the body where injury occurred (Check as many parts as apply):

  • Describe the object or substance that caused the injury:

  • Did the employee request medical evaluation or treatment for the injury?

  • Name of Doctor, Urgent Care, or Hospital employee is going to:

  • Address or Town of Hospital:

  • Is this a hospital emergency room?

  • Was employee transported by ambulance to the hospital?

  • If employee refuses medical treatment, they must read the statements below and sign at the end of the statements.
    - I refuse medical treatment and /or observation for the injury described above.
    - I am aware that at a later time, I may request authorization to seek medical treatment and/or observation for the above described injury from my employer, through my Supervisor or the Human Resources Department.
    - I am aware that at a later time, I may request authorization to seek medical treatment and/or observation for the above described injury from my employer, through my Supervisor or the Human Resources Department.
    - I acknowledge that by declining medical treatment at this time, my employer will not be responsible for any medical expenses or lost wages, unless determined and directed by a medical doctor at a later time.

  • Employee's Signature only if employee is refusing medical treatment at this time.

  • Was employee hospitalized overnight for inpatient treatment?

  • Is the employee's injury a fractured bone?

  • Did the employee receive stitches?

  • Did the employee lose consciousness?

  • Did the doctor prescribe a prescription medication?

  • Did the doctor advise time off of work?

  • Until what date?

  • Did the doctor advise work restrictions?

  • Can your location provide work for this employee within their medical restrictions?

  • Report prepared by (Your Name):

  • Job title of person who prepared report:

  • Telephone of person who prepared report:

  • Signature of person who prepared report:

  • Injured employee's signature:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.